1. The Joint Commission Medical Staff Standards and FPPE/OPPE Compliance
Stephen M. Dorman, M.D.

2. 2013 Scoring and Accreditation Decision Model

3. Standard
A statement that defines the performance expectations and/or structures or processes that must be in place in order for a healthcare organization to provide safe, high quality care, treatment, and services.
An organization is either “compliant” or “
not compliant” with a standard.

4. Element of Performance
The specific performance expectation and/or structure or process that must be in place in order for a healthcare organization to provide safe, high quality care, treatment, and services.
The scoring of EP compliance determines an organization’s overall compliance with a standard.

5. 2013 Scoring/Accreditation Decision Model - Summary
Elements of Performance (EP): types:
A: one observation to cite: 100% compliance
C: two observations to cite: 90% compliance
(D): requires a document or documentation

6. 2013 Scoring/Accreditation Decision Model - Summary
Elements of Performance and other accreditation requirements will be tagged based on their “criticality” – immediacy of impact on quality of care and patient safety as the result of noncompliance.

7. 2013 Scoring/Accreditation Decision Model - Summary
SITUATION DECISION (2): PDA
DIRECT impact: (3): 45 days for ESC
INDIRECT impact: (4): 60 days for ESC

8. 2013 Scoring/Accreditation Decision Model - Summary
If partial compliance or insufficient compliance is not resolved, a progressively more adverse accreditation decision may result:
Provisional, Contingent, Preliminary Denial of Accreditation.

9. 2013 Scoring/Accreditation Decision Model
Accreditation Follow Up Survey:
If any element of performance is cited twice in subsequent surveys, a 45 day follow up survey will occur: AFS 02
Affects both direct and indirect findings

10. 2013 Scoring/Accreditation Decision Model - Summary
Critical Levels:
Immediate threat to life: no a single standard, but condition (APR)
Falsification (APR)
Situational Decision Rule: immediate recommendation of Denial of Accreditation or Contingent accreditation alone.

11. 2013 Scoring/Accreditation Decision Model - Summary
DIRECT impact standard: Sedation
INDIRECT impact standard: Policies
Labels on standards:
(D): Documentation required
(2): Situational Decision Rule
(3): Direct Impact Requirements
(4): Indirect Impact Requirements

12. MS Chapter Outline I. Medical Staff Bylaws
A. Bylaws (revised MS ) (36 A/4)
B. Unilateral Amendment (revised MS ) (1 A/4)
II. Structure and Role of Medical Staff Executive Committee (revised MS ) (12 A/4)

13. MS Chapter Outline
III. Medical Staff Role in Oversight of Care, Treatment, and Services
A. Oversight of Quality of Care (revised MS ) (16 A/4, 1 A/3)
B. Management and Coordination of Care (revised MS ) (10 A/4, 2 A/3)

14. MS Chapter Outline
IV. Medical Staff Role in Graduate Education Programs (revised MS ) (8 A/4, 1 C/4).
V. Medical Staff Role in Performance Improvement
A. Role in Performance Improvement Activities (revised MS ) (12 A/4)
B. Participation in Performance Improvement Activities (revised MS ) (5 A/4)

15. MS Chapter Outline VI. Credentialing and Privileging
A. Determining Resource Availability (revised MS ) (2 A/4)
B. Collecting Information (revised MS )(10 A/4, 1 A/3)
C. Decision Process (revised MS ) (One A/2, 10 A/4, 1 C/4)

16. MS Chapter Outline
D. Reviewing Information (revised MS ) (8 A/4), 1 C/4)
E. Communicating Decision (revised MS ) (5 A/4)
F. Expedited Process (revised MS ) (7 A/4)
G. Temporary Privileges (revised MS ) (6 A/4)

17. MS Chapter Outline VII. Appointment to Medical Staff
A. Recommending Appointment (revised MS ) (5 A/4)
B. Peer Recommendations (revised MS ) (4 A/4).

18. MS Chapter Outline VIII. Evaluation of Practitioners
A. Monitoring Performance (revised MS ) (9 A/4)
B. Use of Monitoring Information (revised MS ) (3 A/4)

19. MS Chapter Outline
IX. Acting on Reported Concerns About a Practitioner (revised MS ) (2 A/4)
X. Fair Hearing and Appeal Process (revised MS ) (5 A/4)
XI. Licensed Independent Practitioner Health (revised MS ) (10 A/4)

20. MS Chapter Outline
XII. Continuing Education for Practitioners (revised MS ) (5 A/4)
XIII. Medical Staff Role in Telemedicine
A. Credentialing and Privileging of Licensed Independent Practitioners (revised MS ) (1 A/4)
B. Recommending Clinical Services to be Provided (revised MS ) (2 A/4)

21. LEADERSHIP
The medical staff has been defined as one of the three components of “leadership”. There is no longer a medical staff leadership interview. When the standards address “leaders”, it is up to the organization to determine which leaders are involved.

22. LD
1: Senior managers and leaders of the organized medical staff work with the governing body to define their shared and unique responsibilities and accountabilities. (A/4)

23. LD.01.05.01 (A/4) 1: NO EP 2: Self-governing
3: Conforms to guiding principles
4: Governing body approves structure
5: Medical staff oversees quality care provided by individuals with clinical privileges
6: Accountable to governing body

24. LD
7: MD/DO/Dentist/Podiatrist responsible for the organization and conduct of the medical staff.
8: There is a SINGLE organized medical staff.

25. LD
1. Governing body, senior managers, and leaders of the organization medical staff work together to identify the skills requires of individual leaders.

26. LD
2: …leaders of the organized medical staff are oriented to:
Mission/Values
Safety and Quality goals
Structure and decision making process
Budget
Population served
Responsibility
Law and Regulation

27. LD.02.02.01 1. Define conflict of interest.
2. Policy on management of conflict of interest.
3. Obtain disclosures of conflicts of interest.
This standard applies to LEADERSHIP

28. LD
1: Ongoing process for conflict management.

29. LD.04.01.05 CMS REQUIRED PHYSICIAN DEPARTMENT DIRECTORS: Anesthesia
Emergency Medicine Services
Respiratory Care Service
Radiology
Nuclear Medicine

30. LD
6: Emergency services are directed and supervised by a qualified member of the medical staff.
7: Physicians direct: anesthesia, nuclear medicine, respiratory care.
9: Anesthesia responsible for ALL anesthesia services (ref. deep sedation)

31. LD.04.02.01 1. Define conflict of interest
2. Policy on conflict of interest
3. Disclosures of conflicts of interest.

32. LD
1: Clinical leaders and medical staff have an opportunity to provide advice about sources of clinical services to be provided through contractual agreement.

33. MS
What is required in the bylaws and new Medical staff communication processes

34. The doctors of medicine and osteopathy and, in accordance with medical staff bylaws, other practitioners are organized into a self-governing medical staff that oversees the quality of care provided by all physicians and by other practitioners who are privileged through a medical staff process.

35. The organized medical staff and the governing body collaborate in a well-functioning relationship, reflecting clearly recognized roles, responsibilities, and accountabilities, to enhance the quality and safety of care, treatment, and services provided to patients.

36. This collaborative relationship is critical to providing safe, high quality care in the hospital. While the governing body is ultimately responsible for the quality and safety of care at the hospital, the governing body, medical staff, and administration collaborate to provide safe, quality care.

37. To support its work, and its relationship with and accountability to the governing body, the organized medical staff creates a written set of documents that describes its organizational structure and the rules for its self-governance.

38. These documents are called medical staff bylaws, rules and regulations, and policies. These documents create a system of rights, responsibilities, and accountabilities between the organized medical staff and the governing body, and between the organized medical staff and its members.

39. Because of the significance of these documents, the medical staff leaders should strive to ensure that the medical staff members understand the content and purpose of the medical staff bylaws and relevant rules and regulations and policies, and their adoption and amendment processes.

40. Of the members of the organized medical staff, only those who are identified in the bylaws as having voting rights can vote to adopt and amend the medical staff bylaws.

41. The voting members of the organized medical staff may include within the scope of responsibilities delegated to the medical executive committee the authority to adopt, on the behalf of the voting members of the organized medical staff, any details associated with Elements of Performance 12 through 36 that are placed in rules and regulations, or policies.

42. Approved. Effective date: 3/31/2011
MS Medical staff bylaws address self-governance and accountability to the governing body
Approved. Effective date: 3/31/2011

43. 1: The organized medical staff develops medical staff bylaws, rules and regulations, and policies.

44. 2: The organized medical staff adopts and amends medical staff bylaws
2: The organized medical staff adopts and amends medical staff bylaws. Adoption or amendment of medical staff bylaws cannot be delegated. After adoption or amendment by the organized medical staff, the proposed bylaws are submitted to the governing body for action. Bylaws become effective only upon governing body approval.

45. 3: Every requirement set forth in Elements of Performance 12 through 36 is in the medical staff bylaws. These requirements may have associated details, some of which may be extensive; such details may reside in the medical staff bylaws, rules and regulations, or policies. The organized medical staff adopts what constitutes the associated details, where they reside, and whether their adoption can be delegated. Adoption of associated details that reside in medical staff bylaws cannot be delegated.

46. 3: (cont): For those Elements of Performance 12 through 36 that require a process, the medical staff bylaws include at a minimum the basic steps, as determined by the organized medical staff and approved by the governing body, required for implementation of the requirement. The organized medical staff submits its proposals to the governing body for action. Proposals become effective only upon governing body approval.

47. 4: The medical staff bylaws, rules and regulations, and policies, the governing body bylaws, and the hospital policies are compatible with each other and are compliant with law and regulation.

48. 5: The medical staff complies with the medical staff bylaws, rules and regulations, and policies.

49. 6: The organized medical staff enforces the medical staff bylaws, rules and regulations, and policies by recommending action to the governing body in certain circumstances, and taking action in others.

50. 7: The governing body upholds the medical staff bylaws, rules and regulations, and policies that have been approved by the governing body.

51. 8: The organized medical staff has the ability to adopt medical staff bylaws, rules and regulations, and policies, and amendments thereto, and to propose them directly to the governing body.

52. 9: If the voting members of the organized medical staff propose to adopt a rule, regulation, or policy, or an amendment thereto, they first communicate the proposal to the medical executive committee. If the medical executive committee proposes to adopt a rule or regulation, or an amendment thereto, it first communicates the proposal to the medical staff; when it adopts a policy or an amendment thereto, it communicates this to the medical staff. This Element of Performance applies only when the organized medical staff, with the approval of the governing body, has delegated authority over such rules, regulations, or policies to the medical executive committee.

53. 10: The organized medical staff has a process which is implemented to manage conflict between the medical staff and the medical executive committee on issues including, but not limited to, proposals to adopt a rule, regulation, or policy or an amendment thereto. Nothing in the foregoing is intended to prevent medical staff members from communicating with the governing body on a rule, regulation, or policy adopted by the organized medical staff or the medical executive committee. The governing body determines the method of communication.

54. 11: In cases of a documented need for an urgent amendment to rules and regulations necessary to comply with law or regulation, there is a process by which the medical executive committee, if delegated to do so by the voting members of the organized medical staff, may provisionally adopt and the governing body may provisionally approve an urgent amendment without prior notification of the medical staff. In such cases, the medical staff will be immediately notified by the medical executive committee. The medical staff has the opportunity for retrospective review of and comment on the provisional amendment.

55. 11: (cont): If there is no conflict between the organized medical staff and the medical executive committee, the provisional amendment stands. If there is conflict over the provisional amendment, the process for resolving conflict between the organized medical staff and the medical executive committee is implemented. If necessary, a revised amendment is then submitted to the governing body for action.

56. 12: The structure of the medical staff. (CMS CoP requirement)
13: Qualifications for appointment to the medical staff. (CMS CoP requirement)
14: The process for privileging and re-privileging licensed independent practitioners, which may include the process for privileging and re-privileging other practitioners. (CMS CoP requirement)

57. 15: A statement of the duties and privileges related to each category of the medical staff (for example, active, courtesy). (CMS CoP requirement)
Note: The word “privileges” can be interpreted in several ways. The Joint Commission interprets it, solely for the purposes of this element of performance, to mean the duties and prerogatives of each category, and not the clinical privileges to provide patient care, treatment, and services related to each category. The Joint Commission is in discussion with CMS to clarify this term’s meaning.

58. 16: The requirements for completing and documenting medical histories and physical examinations. The medical history and physical examination are completed and documented by a physician, an oral maxillofacial surgeon, or other qualified licensed individual in accordance with State law and hospital policy. (CMS CoP requirement)

59. 17: A description of those members of the medical staff who are eligible to vote.
18: The process, as determined by the organized medical staff and approved by the governing body, by which the organized medical staff selects and/or elects and removes the medical staff officers.
19: A list of all the officer positions for the medical staff.

60. 20: The medical executive committee’s function, size, and composition, as determined by the organized medical staff and approved by the governing body; the authority delegated to the medical executive committee by the organized medical staff to act on the medical staff’s behalf; and how such authority is delegated or removed.

61. 21: The process, as determined by the organized medical staff and approved by the governing body, for selecting and/or electing and removing the medical executive committee members.
22: That the medical executive committee includes physicians and may include other practitioners and any other individuals as determined by the organized medical staff.

62. 23: That the medical executive committee acts on the behalf of the medical staff between meetings of the organized medical staff, within the scope of its responsibilities as defined by the organized medical staff.
24: The process for adopting and amending the medical staff bylaws.
25: The process for adopting and amending the medical staff rules and regulations, and policies.

63. 26: The process for credentialing and re-credentialing licensed independent practitioners, which may include the process for credentialing and re-credentialing other practitioners.
27: The process for appointment and re-appointment to membership on the medical staff.
28: Indications for automatic suspension of a practitioner’s medical staff membership or clinical privileges.

64. 29: Indications for summary suspension of a practitioner’s medical staff membership or clinical privileges.
30: Indications for recommending termination or suspension of medical staff membership, and/or termination, suspension, or reduction of clinical privileges.
31: The process for automatic suspension of a practitioner’s medical staff membership or clinical privileges.

65. 32: The process for summary suspension of a practitioner’s medical staff membership or clinical privileges.
33: The process for recommending termination or suspension of medical staff membership and/or termination, suspension, or reduction of clinical privileges.

66. 34: The fair hearing and appeal process regarding the fair hearing and appeal process), which at a minimum shall include:
The process for scheduling hearings and appeals
The process for conducting hearings and appeals
35: The composition of the fair hearing committee.

67. 36: If departments of the medical staff exist, the qualifications and roles and responsibilities of the department chair, which are defined by the organized medical staff and include the following:
Qualifications:
Certification by an appropriate specialty board or comparable competence affirmatively established through the credentialing process.

68. Roles and responsibilities:
Clinically related activities of the department.
Administratively related activities of the department, unless otherwise provided by the hospital.
Continuing surveillance of the professional performance of all individuals in the department who have delineated clinical privileges.
Recommending to the medical staff the criteria for clinical privileges that are relevant to the care provided in the department.

69. Recommending clinical privileges for each member of the department.
Assessing and recommending to the relevant hospital authority off-site sources for needed patient care, treatment, and services not provided by the department or the organization.
Integration of the department or service into the primary functions of the organization.
Coordination and integration of interdepartmental and intradepartmental services.

70. Development and implementation of policies and procedures that guide and support the provision of care, treatment, and services.
Recommendations for a sufficient number of qualified and competent persons to provide care, treatment, and services.
Determination of the qualifications and competence of department or service personnel who are not licensed independent practitioners and who provide patient care, treatment, and services.

71. Continuous assessment and improvement of the quality of care, treatment, and services.
Maintenance of quality control programs, as appropriate.
Orientation and continuing education of all persons in the department or service.
Recommending space and other resources needed by the department or service.

72. Thou Shalt Measure Thou Shalt Analyze Thou Shalt Take Action
The Joint Commissions New Approach to Assessing Physician Performance

73. Why?
Lack of previous success of physicians rigorously dealing with issues related to colleague performance.
Lack of valid data when difficult decisions needed to be made related to physician performance.
Threat of litigation real in light of lack of substantial performance documentation.

74. Why? Peer recommendations were essentially useless.
Physicians would never provide objective references if they knew that substandard performance would be reported.
“Credentialing” always focused on documents.
NPDB only listed most serious issues.

75. Why? Databank reports were not timely.
Physicians were allowed to resign when under the threat of or under actual investigation.
Interruption of referral patterns.
Interference with friendships.
Accusations of financial motivations for competition.

76. Measurement Part I
In the early 90s with the advent of performance improvement, a physician “profile” was to be maintained and used at reappointment every two years.
Areas for measurement have not actually changed much since then.
Compliance was spotty, but not often scored.

77. Measurement Part I Subject to surveyor variability.
Many physician surveyors were not comfortable with the measurement standards and did not understand them.
Most of the data collection at that time was manual.
Profiles frequently indicated “0” for lack of quality issues despite poor performance.

78. Measurement Part II
With a change in Joint Commission leadership, it because apparent that these standards were never scored and were essentially meaningless.
Physician “thinkers” at the Joint Commission became instrumental in changing the approach (and some prodding by CMS).

79. Measurement Part II
First things first: render the current standards meaningful
Implement physician performance measures that were rate based so that they could be compared with peer performance (early 2000).
Comparisons were to be meaningful (meaning statistically analyzed)

80. Measurement Part II Profiles slowly became more meaningful
Hospitals elected to participate in national measurement venues (Care Science, Premier Data, STS, ACC databases etc)
Though data became available, still no action was taken on bad performance.

81. Measurement Part II
There was a paralysis because of lack of benchmark data
Hospitals did not understand that it was acceptable to compare performance to “peer group”
External data was not available because of peer review protection
Low volume providers were not measured

82. Measurement Part III
It became apparent that even though suboptimal performance could be detected at the two year reappointment period, what was being done in advance of that date.
It became “too late” to take action or the reappointment was due and had to be done with less than desirable performance data.

83. Measurement Part IV ONGOING REVIEW
The time frame for the review of physician performance data was discussed at TJC
To be “ongoing”, it was determined that every 2 years was insufficient, and in fact, that every year was insufficient
TJC stated that ongoing review should be conducted every 6-9 months unless “trigger” events had occurred

84. Measurement Part IV
Ongoing review dependent on those performance measures that primarily depend on the performance of an individual provider
These concepts apply not only to physicians, but also others who are credentialed and privileged

85. Measurement Part IV
It also became apparent that privileges that were granted were not based on evidenced-based criteria or any other criteria for that matter
Now the tie is between measured performance and privileges is clear
No data – no privileges
No use of external data (see letter)

86. Measurement Part IV
CMS requires that each privilege granted be based on the assessment of the competence of the physician to exercise that privilege.
There is a move to Core Privileges (assuming that competence is common to the group as defined)
Special request privileges must be individually evaluated
“Laundry lists” are still highly problematic for all the reasons stated

87. The Standard: MS.05.01.01: CLINICAL
The organized medical staff has a leadership role in organization performance improvement activities to improve quality of care, treatment, and services and [patient] safety.
Relevant information developed from the following processes is integrated into performance improvement initiatives and consistent with [organization] preservation of confidentiality and privilege of information.

88. The Standard: MS
1: The organized medical staff provides leadership for measuring, assessing, and improving processes that primarily depend on the activities of one or more licensed independent practitioners, and other practitioners credentialed and privileged through the medical staff process. (See also PI , EPs 1-4)

89. The Standard: MS
2: The medical staff is actively involved in the measurement, assessment, and improvement of the following: Medical assessment and treatment of patients. (See also PI , EPs 1-4)

90. The Standard: MS
3: The medical staff is actively involved in the measurement, assessment, and improvement of the following: Use of information about adverse privileging decisions for any practitioner privileged through the medical staff process.

91. The Standard: MS
4: The medical staff is actively involved in the measurement, assessment, and improvement of the following: Use of medications

92. The Standard: MS
5: The medical staff is actively involved in the measurement, assessment, and improvement of the following: Use of blood and blood components

93. The Standard: MS
6: The medical staff is actively involved in the measurement, assessment, and improvement of the following: Operative and other procedure(s)
Judgment (decision making)
Clinical and Technical Skills

94. The Standard: MS
7: The medical staff is actively involved in the measurement, assessment, and improvement of the following: Appropriateness of clinical practice patterns.
Utilization Review (LOS, Avoidable days, denials)

95. The Standard: MS
8: The medical staff is actively involved in the measurement, assessment, and improvement of the following: Significant departures from established patterns of clinical practice.
All other departments: Pathology, radiology, anesthesiology, ER

96. The Standard: MS
9: The medical staff is actively involved in the measurement, assessment, and improvement of the following: The use of developed criteria for autopsies. (CMS REQUIREMENT)

97. The Standard: MS
10: Information used as part of the performance improvement mechanisms, measurement, or assessment includes the following: Sentinel event data.

98. The Standard: MS
11: Information used as part of the performance improvement mechanisms, measurement, or assessment includes the following: Patient safety data.

99. The Standard: MS.05.01.03: CITIZENSHIP
1: The organized medical staff participates in the following activities: Education of patients and families.

100. The Standard: MS.05.01.03: CITIZENSHIP
2: The organized medical staff participates in the following activities: Coordination of care, treatment, and services with other practitioners and hospital personnel, as relevant to the care, treatment, and services of an individual patient.

101. The Standard: MS.05.01.03: CITIZENSHIP
3: The organized medical staff participates in the following activities: Accurate, timely, and legible completion of patient’s medical records.

102. The Standard: MS.05.01.03: CITIZENSHIP
4: The organized medical staff participates in the following activities: Review of findings of the assessment process that are relevant to an individual’s performance. The organized medical staff is responsible for determining the use of this information in the ongoing evaluations of a practitioner’s competence.

103. The Standard: MS.05.01.03: CITIZENSHIP
5: The organized medical staff participates in the following activities: Communication of findings, conclusions, recommendations, and actions to improve performance to appropriate staff members and the governing body.

104. The Standard: MS
Ongoing professional practice evaluation information is factored into the decision to maintain existing privilege(s), to revise existing privilege(s), or to revoke an existing privilege prior to or at the time of renewal.

105. The Standard: MS
1: The process for the ongoing professional practice evaluation includes the following: There is a clearly defined process in place that facilitates the evaluation of each practitioner’s professional practice. (D means there must be a policy)

106. The Standard: MS
2: The process for the ongoing professional practice evaluation includes the following: The type of data to be collected is determined by individual departments and approved by the organized medical staff. (Performance measures must be defined for CMS in a Medical Staff Plan).

107. The Standard: MS
3: The process for the ongoing professional practice evaluation includes the following: Information resulting from the ongoing professional practice evaluation is used to determine whether to continue, limit, or revoke any existing privilege(s).

108. FOCUSED REVIEW
While it was a good thing to evaluate providers after they had already been working 6 months, it was apparent that there was real risk in the “unknown”.
Peer Recommendations could not be trusted.
Harm could come to patients soon after practice began.

109. FOCUSED REVIEW
There were analogous standards in the Human Resources chapter for an “initial assessment of competency” before hospital staff could carry out job responsibilities independently.

110. FOCUSED REVIEW
It was clear that something was needed on the “front end.”
Next it was determined that in classic “peer review”, cases simply fell off and issues were never closed or casually investigated. There was no accountability for closure of many significant issues.

111. FOCUSED REVIEW The purpose:
Initial assessment of competence of all new physicians or new privileges regardless of experience.
Conduct intensive, planned and “focused” investigations when adverse events occurred (trigger events).
Conduct intensive, planned and “focused” investigations when ongoing performance measurement indicated undesirable performance.

112. Focused Review: New Privileges
Goal: To be conducted as rapidly as possible.
“Volume” of review defined by the medical staff and departments.
Individual plans should be developed to allow the medical staff to know when review has concluded.
Each provider may warrant a tailored plan.
Some departments are completely uniform.

113. Focused Review: New Privileges
Should be conducted in a time frame that is too short for rate based performance measurement: data collection would not be statistically significant for short term.
Evaluation of privilege must be realistic: chart review versus direct observation.
All requirements defined in a plan.
TOP Medical Staff Standard RFI in 2009.

114. The Standard: MS
The organized medical staff defines the circumstances requiring monitoring and evaluation of a practitioner’s professional performance.
- Initial Appointment (new privileges)
- New mid-cycle privilege
- Trigger events
- Variant data

115. The Standard: MS
The focused evaluation process is defined by the organized medical staff. The time period of the evaluation can be extended, and/or a different type of evaluation process assigned. Information for focused professional practice evaluation may include chart review, monitoring clinical practice patterns, simulation, proctoring, external peer review, and discussion with other individuals involved in the care of each patient (e.g., consulting physicians, assistants at surgery, nursing or administrative personnel).

116. The Standard: MS
Relevant information resulting from the focused evaluation process is integrated into performance improvement activities, consistent with the organization’s policies and procedures that are intended to preserve confidentiality and privilege of information.

117. The Standard: MS
1: A period of focused professional practice evaluation is implemented for all initially requested privileges.

118. The Standard: MS
2: The organized medical staff develops criteria to be used for evaluating the performance of practitioners when issues affecting the provision of safe, high quality patient care are identified. (D means Plan)

119. The Standard: MS
3: The performance monitoring process is clearly defined and includes each of the following elements:
- Criteria for conducting performance monitoring
- Method for establishing a monitoring plan specific to the requested privilege
- Method for determining the duration of performance monitoring
- Circumstances under which monitoring by an external source is required

120. The Standard: MS
4: Focused professional practice evaluation is consistently implemented in accordance with the criteria and requirements defined by the organized medical staff.

121. The Standard: MS
5: The triggers that indicate the need for performance monitoring are clearly defined.
Note: Triggers can be single incidents or evidence of a clinical practice trend.

122. The Standard: MS
6: The decision to assign a period of performance monitoring to further assess current competence is based on the evaluation of a practitioner’s current clinical competence, practice behavior, and ability to perform the requested privilege.
Note: Other existing privileges in good standing should not be affected by this decision.

123. The Standard: MS
7: Criteria are developed that determine the type of monitoring to be conducted. (D means this has to be in the plan).

124. The Standard: MS
8: The measures employed to resolve performance issues are clearly defined. (D means it must be in the plan).

125. The Standard: MS
9: The measures employed to resolve performance issues are consistently implemented.

126. NEW CMS REQUIREMENTS
RADIOLOGY
ANESTHESIA

127. RADIOLOGY New CMS requirements for oversight of radiology.
Policies and procedures must comply with nationally recognized standards: ACR
Physician supervision of all contrast administration (CT and MRI). ACR requires a radiologist.

128. RADIOLOGY
Training of all providers who operate radiology equipment: physicians using C-Arm, Fluoroscopy.
Supervision of all ionizing radiology services by director. Best done through radiation safety committee.

129. ANESTHESIA 1: Director of Anesthesia Services
2: “Deep Sedation” now considered anesthesia and is referred to a Monitored Anesthesia Care.
3: MAC may only be administered only by an appropriate practitioner privileged by director of anesthesia services

130. ANESTHESIA
4: Director of anesthesia responsible for all anesthetics (general to local).
5: Director of anesthesia services sets policies for all anesthetic use.
6: Director of anesthesia services decides on how to privilege for moderate sedation.

131. ANESTHESIA
7: Epidurals administered by CRNAs do not require direct supervision unless they become an anesthetic.
8: Post-anesthesia note may be written from the time a patient can participate until discharge or 48 hours whichever comes sooner.

132. ANESTHESIA Practical effects:
Nursing staff will not longer be able to administer anesthesia agents: Etomidate, Ketamine, Pentothal, or Propofol because this is MAC.
Anesthesia will have to privilege for MAC (deep sedation), and recommend privileging process for moderate sedation

133. Scoring
All of the medical staff standards on these issues are “A” meaning 100% compliance is required.
Focused Review: 16% of hospitals cited.
Ongoing Review: 15% of hospitals cited.
Problems with no or low volume providers
Changes to privileges based to data

134. MEC FUNCTION

135. MS
7: Requests evaluation of practitioner when doubt about applicant’s ability to perform privileges (focused review)

136. MS
11: Recommends to governing body: delineation of privileges (no delegation)
12: Receives/acts on reports by committees, departments, groups.

137. MS
Medical staff oversees quality of care, treatments, or services provided by practitioners privileged through the medical staff process
2: Practitioners practices within scope of privileges (DIRECT IMPACT) (100%)

138. MS.03.01.01 4: Leadership in patient safety
5: Oversight of process of analyzing and improving patient satisfaction
6: Minimal content of H&Ps defined
7: MS monitors quality of H&Ps
8: Privileged provider performs H&Ps
9: Others as allowed by laws may perform H&Ps, under a specified physician

139. MS.03.01.01 10: Define when H&P must be validated or countersigned
11: Defines scope of H&P when required for non-inpatient services

140. MS
The management and coordination of each patient’s care, treatment, or services is the responsibility of a practitioner with appropriate privileges
1: LIP with privileges manage and coordinate patient’s care, treatment and services.
2: Hospital educates all LIPs on assessing and managing pain.

141. MS
3: Patient’s general medical condition managed by a doctor of medicine or osteopathy.
4: Circumstances warranting consultation
5: Consultations obtained when warranted
6: Coordination of care among practitioners

142. CMS COP Change
Non-privileged providers as allowed by law may order outpatient care.
Verification of their authority to order the care or treatment.
Policy on which orders will be accepted and under what circumstances.
Still requires for patient to be under the general medical care of a privileged provider.

143. MS.04.01.01 Graduate Medical Education
1: Defined process for supervision
2: Written description of roles and responsibilities and patient care activities are provided to medical and hospital staff
3: Mechanisms about decisions about progressive involvement
4: Define who may write orders and requirements for countersignature

144. MS
5: Communication between committee overseeing GME and hospital medical staff and governing body
6: GME communicates about safety and quality of care, supervisory need to MEC and governing body
7: Communicate from local hospital to GMEC

145. MS
8: Quality of care, treatment, services educational need to governing body of sponsoring hospital
9: Compliance with residency review committee citations.

146. MS
The [organization] collects information regarding each practitioner’s current license status, training, experience, competence, and ability to perform the requested privilege.

147. MS.06.01.03 1: Clearly defined process
2: Process based on recommendations by medical staff
3: Process approved by governing body
4: Outlined in bylaws
5: Verify that the REQUESTING individual be identified by VIEWING official ID.

148. MS.06.01.03 6: Primary Source verification of:
The applicant’s current licensure at time of initial granting, renewal, and revision of privileges, and at the time of license expiration.
The applicant’s relevant training.
The applicant’s current competence.

149. MS
The decision to grant or deny a privilege(s), and/or to renew an existing privilege(s), is an objective, evidenced-based process.

150. MS
1: All licensed independent practitioners that provide care possess a current license, certification, or registration, as required by law and regulation. (SITUATIONAL DECISION)

151. MS.06.01.05 2: Criteria based privileges include:
Current licensure and/or certification, as appropriate, verified with the primary source.
The applicant’s specific relevant training, verified with the primary source.
Evidence of physical ability to perform the requested privilege.
Data from professional practice review by an organization(s) that currently privileges the applicant (if available).
Peer and/or faculty recommendation.
When renewing privileges, review of the practitioner’s performance within the hospital.

152. MS
3: All of the criteria used are consistently evaluated for all practitioners holding that privilege
4: Process defined for granting, renewing, revising privileges
5: Process is approved by medical staff

153. MS.06.01.05 6: Applicant submits health statement.
7: Hospital queries NPDB at initial privileges, renewal of privileges, and when new privileges requested.

154. MS.06.01.05 8: Peer Recommendation includes:
Medical/Clinical knowledge.
Technical and clinical skills.
Clinical judgment.
Interpersonal skills.
Communication skills.
Professionalism.

155. MS
9: Before recommending privileges, the organized medical staff also evaluates the following:
Challenges to any licensure or registration.
Voluntary and involuntary relinquishment of any license or registration.
Voluntary and involuntary termination of medical staff membership.
Voluntary and involuntary limitation, reduction, or loss of clinical privileges.
Any evidence of an unusual pattern or an excessive number of professional liability actions resulting in a final judgment against the applicant.
Documentation as to the applicant’s health status.
Relevant practitioner-specific data as compared to aggregate data, when available.
Morbidity and mortality data, when available.

156. MS
10: The hospital has a process to determine whether there is sufficient clinical performance information to make a decision to grant, limit, or deny the requested privilege. (CMS)
11: Completed applications for privileges are acted on within the time period specified in the medical staff bylaws.

157. MS
12: Information regarding each practitioner’s scope of privileges is updated as changes in clinical privileges for each practitioner are made.

158. MS
The organized medical staff reviews and analyzes all relevant information regarding each requesting practitioner’s current licensure status, training, experience, current competence, and ability to perform the requested privilege.

159. MS
1: The information review and analysis process is clearly defined.
2: The hospital, based on recommendations by the organized medical staff and approval by the governing body, develops criteria that will be considered in the decision to grant, limit, or deny a requested privilege.

160. MS
NEW EP: July 2010
3: Gender, race, and national origin are not used in making decisions regarding the granting or denying of clinical privileges.

161. MS
4: The hospital completes the credentialing and privileging decision process in a timely manner.
5: The hospital’s privilege granting /denial criteria are consistently applied for each requesting practitioner.
6: Decisions on membership and granting of privileges include criteria that are directly related to the quality of health care, treatment, and services.

162. MS
7: If privileging criteria are used that are unrelated to quality of care, treatment, and services or professional competence, evidence exists that the impact of resulting decisions on the quality of care, treatment, and services is evaluated.

163. MS
8: The governing body or delegated governing body committee has final authority for granting, renewing, or denying privileges.
9: Privileges are granted for a period not to exceed two years.

164. MS
The decision to grant, limit, or deny an initially requested privilege or an existing privilege petitioned for renewal is communicated to the requesting practitioner within the time frame specified in the medical staff bylaws.

165. MS
1: Requesting practitioners are notified regarding the granting decision.
2: In the case of privilege denial, the applicant is informed of the reason for denial.
3: The decision to grant, deny, revise, or revoke privilege(s) is disseminated and made available to all appropriate internal and external persons or entities, as defined by the hospital and applicable law.

166. MS
4: The process to disseminate all granting, modification, or restriction decisions is approved by the organized medical staff.
5: The hospital makes the practitioner aware of available due process or, when applicable, the option to implement the Fair Hearing and Appeal Process for Adverse Privileging Decisions.

167. MS
An expedited governing body approval process may be used for initial appointment and reappointment to the medical staff and for granting privileges when criteria for that process are met.

168. MS
1: The organized medical staff develops criteria for an expedited process for granting privileges. (two voting members)
2: The criteria provide that an applicant for privileges is ineligible for the expedited process if any of the following has occurred:
- The applicant submits an incomplete application.
- The medical staff executive committee makes a final recommendation that is adverse or has limitations.

169. MS
Ineligible if:
3: There is a current challenge or a previously successful challenge to licensure or registration.
4: The following situations are evaluated on a case-by-case basis and usually result in ineligibility for the expedited process: The applicant has received an involuntary termination of medical staff membership at another hospital.

170. MS
Ineligible if:
5: The applicant has received involuntary limitation, reduction, denial, or loss of clinical privileges.
6: The hospital determines that there has been either an unusual pattern of, or an excessive number of, professional liability actions resulting in a final judgment against the applicant.

171. MS
7: The organized medical staff uses the criteria developed for the expedited process when recommending privileges.

172. MS
Under certain circumstances, temporary clinical privileges may be granted for a limited period of time.
1: Temporary privileges are granted to meet an important patient care need for the time period defined in the medical staff bylaws.

173. MS
2: When temporary privileges are granted to meet an important care need, the organized medical staff verifies current licensure and current competence.

174. MS
3: Temporary privileges for new applicants may be granted while awaiting review and approval by the organized medical staff upon verification of the following:
Current licensure.
Relevant training or experience.
Current competence.

175. MS.06.01.13 Verification (cont):
Ability to perform the privileges requested.
Other criteria required by the organized medical staff bylaws.
A query and evaluation of the National Practitioner Data Bank (NPDB) information.
A complete application.
No current or previously successful challenge to licensure or registration.
No subjection to involuntary termination of medical staff membership at another organization.
No subjection to involuntary limitation, reduction, denial, or loss of clinical privileges.

176. MS
4: All temporary privileges are granted by the chief executive officer or authorized designee.
5: All temporary privileges are granted on the recommendation of the medical staff president or authorized designee.
6: Temporary privileges for new applicants are granted for no more than 120 days.

177. MS.07.01.01 1. Criteria for membership
2. Criteria reflect quality of care.
3. Appointment and reappointment do not exceed two years (730 days) (100%)
4. Non-discrimination
5. Membership recommended by medical staff and approved by governing body.

178. Telemedicine
CMS REQUIREMENTS

179. Definitions
Hospital: location where patient receives telemedicine services
Distant Site: where the physician is remotely who is providing services
Entity: a non-hospital providing location

180. Governing Body
(Hospital) Agreement to provide services with “distant site.”
Governing body of “distant site” responsible for compliance in writing.
(Hospital) May locally privilege using documents provided by distant site.
Distant site is a “contractor” for services.

181. Governing Body
Distant site provides these services in a manner that allows the hospital to be compliant.

182. Medical Staff
Medical staff may rely on credentialing and privileging decision of distant site (proxy).
1). Distant site must be medicare-participating hospital.
2). Privileged at distant site, and list provided to hospital.
3). Individual holds license in state where patients are located.

183. Medical Staff
4). Hospital performs internal review of performance and sends to “distant site.”
5). Includes all adverse events and complaints.

184. Medical Staff
Requirements if the “distant site” is not a medicare participating hospital but is a non-medicare participating “entity”.
1. Agreement requires that the services be furnished in a manner that permits the hospital to be in compliance with CMS requirements.

185. Medical Staff: ENTITY
2). Distant entity credentialing and privileging process meets CMS standards.
3). Distant entity providers privilege list/delineations.
4). Holds license in state where patient located.
5). Hospital sends performance review to distant entity.

186. Medical Staff: ENTITY
6). Criteria for privileging established.

187. Critical Access Hospitals
Requires distant site to have:
1). Medical staff structure that complies with CMS medical staff requirements.
All other structures are same as for hospitals.

188. Critical Access Hospitals
1). Quality and appropriateness of the diagnosis and treatment reviewed by:
One hospital in the network
One QIO
One qualified entity defined by state rural health plan
Written agreement with hospital

189. Disaster Privileges
Moved to the new Emergency Management chapter. Process consistent for all volunteer providers: LIPs, and NON-LIPs

190. QUESTIONS
Q&A

191. REFERENCE DOCUMENTS

192. Ongoing Physician Performance
Components of a compliant process

193. CMS
CMS requires that physician performance plans be defined in writing. This is scored as part of quality and not credentialing or privileging.

194. Basics
Indicators must be established that are appropriate to each physician. Generally this is specialty based.
Components to be included are delineated in MS and MS

195. Indicator Development
Must originate at the department level
Must be approved by department chairman
Must be approved by MEC
Must be approved by Governing body

196. Indicator Development
Many of appropriate indicators are already being measured within the hospital:
Core measures (internal medicine)
SCIP measures (procedural specialties)
Traditional review (LOS, denials)
Medical records

197. Indicator Development
Some measures have been part of generic screens:
Returns to the operating room
Returns to the emergency room
Surgical site wound infections
Critical events

198. Indicator Development
Some indicators are antiquated:
C-Section rate
Appropriateness of Appendectomies

199. Indicator Development
Commonly used indicators:
ASA Indicator set:
Prolonged recovery for anesthesia
Failed regional anesthesia
Hypotension
Hypoxia
Difficult intubation

200. Indicator Development
Obstetrics:
Fetal age at C-Section delivery
3rd and 4th degree lacerations for delivery (morbidity)
Appropriate management of labor (as defined)
Use of analgesia

201. Indicator Development
Radiology:
“Over-reads” for diagnostic imaging
Appropriateness and outcomes from invasive radiology procedures

202. Indicator Development
Surgical Specialties:
Appropriateness of selected procedures (high risk, problem-prone)
Outcomes:
Surgical site wound infection
Other post-operative morbidity
Mortality

203. Indicator Development
Psychiatry:
Multi-drug therapy
Restraint need
Recidivism rate
Appropriateness of evaluations

204. Data Use
The periodicity of data collection must be defined, and the method of collecting data defined:
Retrospective review
Concurrent review

205. Data Use
Once the indicators are established and methodology developed for collection of the data then the task of analysis must occur.
Data analysis: Conversion of all raw numbers to rate based performance.
Incumbent on having good denominator data.

206. Data Use
Some data may be available on an aggregate basis, but not at a practitioner specific level:
Core Measure data
SCIP data
Other PI data

207. Data Use
Once the rate based data is collected on an individual basis, it must be compared to “peer” or departmental performance.
The comparison must be analytical, and indicate if sub-par performance is a simple data variant, or truly statistically significant.
Tools will be required for this analysis.

208. Data Use
Once the organization has the ability to define, collect, and analyze the data, then the periodicity of review must be determined.
Ongoing performance monitoring has been stated by TJC to be at an interval not greater than every 6-9 months.

209. Data Use
Now that data collection and analysis is ongoing, it should be easy to establish a comprehensive physician based reappointment profile for reappointment.
Performance data must then go to the board for their consideration when reappointments are being granted.

210. Data Use What will go to board? Normal data? Variant data?
Who will present this to board with credentials file?

211. 2010 What determines “pass” or “fail”?
How will further evaluation be conducted?
What will happen if the physician performance in a sub-optimal?
How long will you wait to take action.

212. Indicators
Some events should not be “rated based” such as sentinel or critical events. Even one is too many, such as “intra-operative anesthesia death.”
These types of cases should be defined as requiring immediate “focused review.”

213. Plan Define indicators Obtain department and leadership approval
Formulate a “data inventory” and specify methodology for data collection
Establish reporting chain of command
Write the plan
Define focused review

214. Plan Define ongoing review
Establish a methodology to write focused review plans for all new appointments to the medical staff.
Establish methodology for statistical analysis.

215. Challenges
Most data collection is manual. Extra staff will probably be required.
Data collection and analysis is not a job that is normally undertaken by the medical staff office, but usually originates from the performance measurement department (quality).
Expertise must be acquired for analysis.

216. FAIR HEARING
Unchanged for

217. MEDICAL STAFF STANDARDS
DUPLICATIVE AFTER MS BECOMES EFFECTIVE

218. MS
The organized medical staff, pursuant to the medical staff bylaws, evaluates and acts upon reported concerns regarding a privileged practitioner’s clinical practice and/or competence.
STANDARD WILL BE RENDERED MOOT AFTER MS BECOME EFFECTIVE

219. MS
1: The hospital, based on recommendations by the organized medical staff and approval by the governing body, has a clearly defined process for collecting, investigating, and addressing clinical practice concerns.

220. MS
2: Reported concerns regarding a privileged practitioner’s professional practice are uniformly investigated and addressed, as defined by the hospital and applicable law.